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t I Z UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK IS�J i11D OPERATING PERMIT APPLICATION-TANK INFORMATION(One form UST) TYPE OF ACTION (Check one item only. Fm an UST permanent closure or removal,complete only this section I,II,I ns H,N,and IX below) 130 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT and Sectio ® 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 3 dd - -75� BUSINESS NA S as F ILITY NAME or D A-Doing Bnusiness As) 3 BUSINESS SITE ADDRESS ^ a Im C CITY N O S'F ilt t'7Fi f{-t/ ' '9-y.J 7�C�) IL TANK DESCRIPTION TANK ID k 432 TANK MANDFACID433 TANK CONFIGURATION: THIS TANK IS 434 rD N Til l� Al�"I C Nom- ❑1 STAND-ALONE TANK d V U ( / O^3 E M A COMPARTMENTED UNIT. aeon forotli in as uni DATE UST SYS MIN TAILED 4Js TANK ACII'Y Qd GALLONS • NUMBER OF COMPARTMENTS IN THE UNIT 437 C_ a III TANK USE AND CONTENTS TANK USE la MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Wudc,Uee3 W) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252BL5(cq ❑ &OTHER GENERATOR FUEL ❑ 95.UNKNOWN 0 99 OTHER (Specify): 419a CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 4a `p?DIBSEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUMS g,N NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL I I.OTHER NON-PETROLEUMS i : 410b IV. TANK.CONSTRUCTION TYPEOFTANK ❑ I.SWGLEWALL 4ff 2-DOUBLEWALL 0 93.UNKNOWN 03 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS 6.INTERNAL BLADDER 4µ ❑ 7.STEEL+INTERNAL MING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4/4s SECONDARY CONTAINMENT ❑ 1.STEEL3.FIBERGLASS ElMB 6.EXTERIOR MERANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN 02 9.OTHER(S 44p OVERFILL PREVENTION LAUDffiLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 432. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT!WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED $2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3. NAL SUCTION ❑ 4.SAFES UCTION 23 CCR§263 p(3) 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 964 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTH" " ( S pecify): 6N SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC a6ab ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 964c PIPING?URBINE CONTAINMENT SUMP TYPE I.SINGLE WALL .DOIffiLE WALL ❑ gp,NONE 9694 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL ET4.FIBERGLASS Iff 10.RIGID PLASTIC U 90.NONE 0 99.OMER(Speeify) 464e 46hi VENT SECONDARY CONTAINMENT 0 I.STEEL 0 4.FIBERGLASS El 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 9Nf 46 n VR PRIMARY CONTAINMENT 0 1.STEEL AD 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464g 469 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 469h 469h1 VEIN PIPING TRANSITION SUMP TYPE L SINGLE WAIL 2.DOUBLE WALL 0 90.NONE 464i. RISER PRIMARY CONTAINMENT UH I.STEEL 4J4.1,115MULASS 10.RIGID PLASTIC U W.NONE Lj 99.OTHER(Spaify) 9641 464'1 [CONSTRU R SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 9o.NONE ".OTHER(Specify) 469t 469k1 COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATF/B07TOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CRON'TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 969e CONSTRUCTION MATERIAL 0 I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC (] 99.OTHER( ) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 441. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify 14t thls UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in fn n Brace wi d uitements. APPLICANT SIGNATURE /� � DATE L970_ APPLICANT NAME print) U r ^` 471. APPLICANTTIILE M A-""''A`"'�1 r`1 r`a�. /� �` �f 4n. UPCF UST-B-1/2 ' " Rev.(12(2007)